Page 1019 - Saunders Comprehensive Review For NCLEX-RN

Content Area: Pediatrics: Throat/Respiratory
Health Problem: Pediatric-Specific: Tonsillitis and Adenoiditis
Priority Concepts: Clinical Judgment; Clotting
Reference: McKinney et al. (2018), p. 1041.

349. Answer: 1

Rationale: A myringotomy is the insertion of tympanoplasty tubes into the middle
ear to promote drainage of purulent middle ear fluid, equalize pressure, and keep
the ear aerated. The nurse must instruct parents regarding the administration of
antibiotics. Antibiotics need to be taken as prescribed, and the full course needs to be
completed. Options 2, 3, and 4 are incorrect. Antibiotics are not tapered but are
administered for the full course of therapy.
Test-Taking Strategy: Focus on the subject, understanding of the instructions
about antibiotics. Recall that antibiotics must be taken for the full course, regardless
of whether the child is feeling better. This will assist in directing you to the correct
option.
Level of Cognitive Ability: Evaluating
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Evaluation
Content Area: Pediatrics: Eye/Ear
Health Problem: Pediatric-Specific: Acute and Chronic Otitis
Priority Concepts: Client Education; Safety
Reference: Hockenberry, Wilson, Rodgers (2017), pp. 646-647.

350. Answer: 2

Rationale: Strabismus is a condition in which the eyes are not aligned because of
lack of coordination of the extraocular muscles. The nurse may suspect strabismus in
a child when the child complains of frequent headaches, squints, or tilts the head to
see. Other manifestations include crossed eyes, closing one eye to see, diplopia,
photophobia, loss of binocular vision, or impairment of depth perception. Options 1,
3, and 4 are not indicative of this condition.
Test-Taking Strategy: Eliminate options 1 and 4 first because they are comparable
or alike and relate to hearing. To select from the remaining options, recall that this is
a condition in which the eyes are not aligned because of lack of coordination of the
extraocular muscles.
Level of Cognitive Ability: Analyzing
Client Needs: Physiological Integrity
Integrated Process: Nursing Process—Assessment
Content Area: Pediatrics: Eye/Ear
Health Problem: Pediatric-Specific: Eye Focus and Alignment Disorders
Priority Concepts: Clinical Judgment; Sensory Perception
Reference: Hockenberry, Wilson, Rodgers (2017), p. 543.

351. Answer: 1, 5, 6

1019